Writing Well: The Long-Term Effect on Empathy, Observation, and Physician Writing Through a Residency Writers' Workshop

In medicine, the process of narrative writing can provide a means of understanding one's own experiences, as well as those of others. Creative writing exercises in graduate medical education have traditionally focused on reflective writing as a way to process emotional reactions,^1–7  counteract the loss of empathy, and address burnout and cynicism associated with medical training.^8,9 

The focus of the Yale Internal Medicine Residency Writers' Workshop is not on reflection, but on the craft of writing. The workshop's initial cohort of participants reported that the focus on craft increased self-awareness and awareness of patients' humanity.¹⁰  After the workshop's 10th year, we sought to learn whether participating in this workshop had long-term effects on empathy, the ability to observe, and future writing.

The internal medicine department at Yale University trains 206 residents in traditional, primary care, and medicine-pediatrics residency programs.

A total of 130 residents participated in the initial 10 years of the writers' workshop from 2003 to 2013. The majority of participants (104) were from internal medicine, while 26 were from other specialties, including radiology, obstetrics and gynecology, anesthesiology, psychiatry, pediatrics, surgery, and emergency medicine.

The Residency Writers' Workshop is an annual 2-day workshop. Participation is limited to 12 to 14 participants in order to provide sufficient time to review each piece. The workshop is currently facilitated by 2 physician-writer faculty members (L.S. and A.R.). Estimated information regarding faculty time and workshop budget are provided in table 1. Workshop participants read all submissions before the workshop. On day 1, the group provides feedback on each written piece. Discussion includes style, efficient storytelling, and use of descriptive and precise language. The workshop includes creative writing exercises, such as “Places,” in which groups of 2 participants are instructed to leave the workshop room and find another location inside or outside. Each person writes a description of the location using language that engages all of the senses. Participants then return and share with the group. On day 2, participants share revisions from the previous evening and discuss ethical issues in writing and publication.

In the 2 months following the workshop, participants revise their pieces with guidance from workshop faculty. Finished works are compiled in an annual publication, Capsules. Residents then give a reading for the medical community, and a visiting physician-writer presents medical grand rounds.

In April 2014, the 130 former workshop participants (2003–2013) were e-mailed a link to an online survey via Qualtrics (Provo, Utah). Prospective respondents were informed that responding to the survey denoted informed consent to participate. Periodic reminders were sent, and the survey closed in November 2014.

Survey questions included rating the workshop's influence on one's ability for careful observation, ability to be empathic, improvement in writing, and continued informal (diary, personal journal, etc) and formal (publication) writing, on a 5-point Likert scale (1, strongly agree, to 5, strongly disagree). Respondents were also asked to describe the most valuable component of the writers' workshop.

Simple statistics were derived from survey responses using the statistical reporting program supplied in Qualtrics. Narrative data per question were downloaded and placed in Microsoft Word (Redmond, Washington) for analysis. Four study personnel (M.L., J.E., L.S., and A.R.) reviewed free-text survey responses for 7 questions requiring written narrative answers. In pairs, reviewers performed open coding to identify themes for each of the 7 areas of response. Each dyad corresponded to reach consensus on codes. All 4 investigators discussed the preliminary codes and reached consensus on a final coding scheme. Final codes were then applied to all narrative questions by 1 investigator (M.L.), and then used by all 4 study personnel to achieve consensus on themes emerging from the textual responses.

This study was approved with exempt status by the Yale School of Medicine Human Investigation Committee.

The final number of completed surveys was 89 of 130 (68% of the total population of participants). Not all participants completed all questions.

A total of 72 of 85 participants (85%) agreed or strongly agreed that workshop participation influenced their ability for careful observation. Participants described an increased attention to clinical detail after the workshop, including physical examination findings, clinical atmosphere, and patients' nonverbal cues (see table 2a for a representative quote).

Some participants commented that the workshop helped them frame patient details in a story format, which then helped them collect clinical information in an organized fashion. Others noted that they learned to include more nuanced descriptions and less jargon in their clinical documentation (table 2b).

More than half of participants (51 of 77, 66%) felt that the workshop affected their empathy. Examining patient encounters through narrative writing and editing, as well as through listening to other participants share stories about experiences with patients, helped achieve a deeper understanding of the lived experiences of patients (table 2c and 2d).

Many participants described increased empathy toward their colleagues as a result of the workshop (table 2e.)

Nearly all of the participants (69 of 77, 90%) agreed or strongly agreed that the workshop improved their writing ability. Many noted that their writing improved through learning literary tools, such as “show, don't tell” and starting a story in the middle of an action (table 2f).

Participants expressed appreciation for the feedback and revision process during the workshop and for the focus on elements of good writing (table 2g).

Most participants (52 of 77, 68%) reported that they continued to write formally (for publication) or informally (diary, personal journal, etc; 41 of 77, 53%). They felt that they had become part of a community of writers, which increased confidence in their writing and editing. They also described an increased interest in reading nonacademic works. Some continued to use writing to process difficult clinical encounters (table 2h).

A total of 32 of 77 participants (42%) indicated that they had pursued additional writing opportunities to improve their skills, including writing classes, conferences, and collaborative writing projects.

Some participants indicated that providing and receiving feedback in a group was the most valuable workshop component. They expressed gratitude at having found a community of physician-writers. Some described learning the value of writing as well as an increased motivation to seek publication. Some simply appreciated the value of having time allocated to write and reflect (table 2i).

Participation in a writing workshop with a focus on craft may have long-lasting effects on resident physicians' observation skills, empathy, and continued writing.

There is renewed interest in training physicians to be more empathic. Medicare and Medicaid reimbursement is tied to patient satisfaction scores. Numerous formal programs have been created to bolster the empathy of resident physicians.^11–13 

Some argue that decreased time at the bedside and lack of focus on physical examination skills have resulted in poorer diagnostic skills.^14,15  Several training programs have used visual arts to improve observation skills, but few have examined the role of the literary arts in teaching observation.^16–23  In a review, Wellbery and McAteer²⁴  wrote that “literary precision provides an educational bridge to recognizing the importance of detail in the clinical realm.” Our participants felt that training in writing improved these skills beyond the time of the workshop.

Our study has several limitations. Participants are current and former medical residents who elected to take part in a writers' workshop, and their inherent interest in writing likely included a high baseline level of empathy and observation skills. We lack objective data about participants' level of empathy, observation skills, and writing skills prior to and after the workshop. Our data are limited to 1 institution, and results may not be generalizable. In future studies, participants' empathy and observation skills should be directly measured.

Despite the competing demands of residency training, participants in the first 10 years of the Yale Internal Medicine Residency Writers' Workshop completed meaningful narratives and reported effects on empathy, observation, and future writing.